Ventriculoperitoneal (VP) Shunt Complications: Diagnosis & Treatment
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Ventriculoperitoneal Shunt Complications In Children: An Evidence-Based Approach To Emergency Department Management

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Focused History
      1. Signs And Symptoms
        • Clinical Signs And Symptoms
        • Seizure
        • Myelodysplasia
      2. Summary
    2. Physical Examination
    3. Pumping The Shunt
  9. Diagnostic Studies
    1. Imaging
  10. Treatment
  11. Special Circumstances/Populations
    1. No Neurosurgeon In-House
    2. Ventriculoatrial And Ventriculopleural Shunts
  12. Controversies And Cutting Edge
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For Patients With VP Shunt Complications
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For The Management Of Suspected VP Shunt Malfunctions
  19. Clinical Pathway For The Management Of Suspected VP Shunt Infections
  20. Tables and Figures
    1. Table 1. Shunt Complications
    2. Table 2. Key Questions For Patients With A Ventriculoperitoneal Shunt Who Present With Acute Illness
    3. Table 3. Signs And Symptoms Of Shunt Complications, Acute Versus Subacute & Chronic
    4. Table 4. Clinical Predictors Of Shunt Complications
    5. Table 5. Emergency Department Evaluation Of Shunt Complications
    6. Table 6. Management Of Specific Shunt Complications
    7. Figure 1. Hydrocephalus, Dilated Ventricles Seen On Head Computed Tomography
    8. Figure 2. Shunt Components Of Ventriculoperitoneal And Ventriculoatrial Shunts
    9. Figure 3. Slit-Like Ventricles On A Head Computed Tomography Scan
    10. Figure 4. Cerebrospinal Fluid Pseudocyst On A Computed Tomography Scan
    11. Figure 5. Radiographic Images From A Shunt Series
    12. Figure 6. Fracture Of A Ventriculoperitoneal Shunt
  21. References

Abstract

Although much is known about ventriculoperitoneal shunts, there are still large gaps in the literature and no evidence-based guidelines on management. To date, there is no general consensus on workup and treatment, and there are many differing diagnostic and therapeutic strategies for management of complications. Ventriculoperitoneal shunt complications can be separated into 3 categories: mechanical failure, infection, and functional failure. Knowing the basic anatomy of ventriculoperitoneal shunts, the time of shunt placement, and the clinical manifestations suggestive of potential complications can help with the management of patients with ventriculoperitoneal shunts. This review summarizes the literature on complications of ventriculoperitoneal shunts, examines the literature regarding the workup and management of patients with ventriculoperitoneal shunts, and makes recommendations for the management of these patients in the emergency department.

Case Presentations

A 7-year-old girl with a history of a VP shunt presents with a headache for 2 days and worsening fever. The patient’s mother states that the child had a shunt placed during her first year of life for congenital aqueductal stenosis. The patient is febrile in the ED, with a temperature of 38.6°C, but is nontoxic. Her other vital signs are: heart rate, 118 beats/min; respiratory rate, 20 breaths/min; blood pressure 98/62 mm Hg; and oxygen saturation, 100% on room air. Her physical examination is unremarkable except for a mildly erythematous throat. What are important points on your history that should be elicited for a patient with a VP shunt and fever? If you are concerned about a VP shunt infection, what laboratory studies should be ordered? Do you need to order any imaging studies to look for a possible shunt malfunction? Should you call this child’s neurosurgeon?

A 3-year-old girl with a VP shunt, who is suffering from altered consciousness and persistent vomiting, is brought to your community ED via EMS. The patient’s mother states the child has been drowsy for the past few weeks. Upon arrival, you place the girl on a monitor and a nonrebreather mask and obtain the following vital signs: heart rate, 76 beats/min; respiratory rate, 20 breaths/min; blood pressure, 110/65 mm Hg; and oxygen saturation, 100% on the nonrebreather. Upon primary survey, the patient’s airway is intact, but there are coarse breath sounds bilaterally over her chest. Her capillary refill is < 2 seconds. Her GCS score is 9, and you note that one pupil seems to be more dilated than the other and appears to be sluggishly reactive. The patient is not responding to your commands. What could be causing this patient’s symptoms? Without a neurosurgeon in-house, what should your management of this patient be? Does the patient need imaging prior to any procedures?

A 5-year-old boy with a history of constipation, mild developmental delay, and a VP shunt presents with 1 week of vomiting. His mother states he is chronically on stool softeners. For the past week, the patient has had 2 to 3 episodes of nonbloody, nonbilious vomiting per day. He has not had diarrhea, but his last stool, which was earlier today, was watery. The mother states he has not been complaining of headaches, but has been eating and drinking less. His vital signs are stable upon arrival. The patient’s examination is normal, including the neurologic examination, except for mild periumbilical tenderness. There is no rebound or guarding upon abdominal palpation. You realize that this could be a typical presentation of constipation, but the patient’s VP shunt makes you consider possible shunt complications. You begin to wonder if this could possibly be a shunt obstruction or infection. What steps should be taken in the management of this patient? What history is important in this case? What physical examination findings might help with the diagnosis?

Introduction

Ventriculoperitoneal (VP) shunts are the treatment of choice for patients with hydrocephalus, an excessive accumulation of cerebrospinal fluid (CSF) within the brain caused by an imbalance between CSF production, flow, or absorption. Most commonly, pressure builds up proximal to an obstruction, leading to ventricular dilatation and raised intracranial pressure (ICP).1 (See Figure 1). The pathophysiology of hydrocephalus has been known since the 1800s, but effective treatment was not available until the 1950s, when John Holter developed a shunt to allow drainage of excess CSF, in an attempt to treat his own son, who was suffering from hydrocephalus.2 Since then, the standard treatment of hydrocephalus has been the insertion of a ventricular shunt, and it has dramatically reduced the morbidity and mortality of hydrocephalus.3,4

A shunt consists of 4 major components: a proximal catheter, a 1-way valve, a reservoir, and a distal catheter.5 (See Figure 2.) Most neurosurgeons place shunts that contain medium-pressure valves and drain CSF continuously when the pressure in the ventricles is > 10 mm Hg.6 The proximal catheter is normally inserted in the parieto-occipital region of the lateral ventricle, and the 1-way valve and reservoir run behind the ipsilateral ear. The distal portion of the catheter is tunneled down through the neck and chest wall and, most commonly, ends in the peritoneal cavity.3,5 Other areas where the catheter can terminate include the pleural cavity, atrium, and gallbladder; however, the peritoneal cavity is the preferred site of termination, as it is associated with the fewest complications.7 If placed in infancy or childhood, the distal catheter has extra length in the abdomen to allow for growth of the patient. Many newer valves allow for the opening pressure to be adjusted externally via a magnetic or electromagnetic device; these “programmable" shunts obviate the need for surgery to change the pressure setting.1

Unfortunately, VP shunts are not long-lasting, and revision may be required 1 to 2 times every 10 years.3 The Pediatric Shunt Design Trial was a randomized controlled trial that compared differ-ent types of shunts in patients with hydrocephalus. According to this prospective study, approximately one-third of shunts require revision in the first postoperative year and > 50% fail by the second year after insertion.8 This study, as well as others, found failure to be independent of valve type.1,7,8 There are several risk factors for complications, including: younger age, history of prematurity, number of revisions, and shorter time from insertion to first revision.4,9-11 Ethnicity also has been linked to shunt complications. Specifically, blacks, Hispanics, and Native Americans have a higher rate of complications compared to Asians and whites.4,12,13 The number of shunt placements is increasing each year. The annual malfunction rate is projected to be as high as 5%.5,14 The mortality rate from a shunt malfunction can be as high as 1% to 2%.15

Both the history and physical examination are very important when evaluating a patient with a possible shunt complication, and will guide the emergency clinician in making management decisions. This issue will help practitioners identify possible shunt complications, determine necessary diagnostic and management steps, and decide appropriate dispositions.

Critical Appraisal Of The Literature

A literature search was performed in PubMed using the search terms ventriculoperitoneal shunt, VP shunt, complication, pediatric, paediatric, infant, child, and adolescent. For completeness, the terms ventriculoatrial shunt, VA shunt, and ventriculopleural shunt were also searched. More than 1300 articles published since 1970 were found, and over 250 articles were reviewed, based on the clinical relevance of their abstracts. Supporting articles were gathered from related articles and the reference lists of reviewed articles. The search produced mostly case reports, as well as retrospective and prospective studies that were mostly chart reviews. There was a limited number of large studies, and very few randomized controlled trials were found. Textbooks pertaining to hydrocephalus and VP shunt management were used for general information.

Risk Management Pitfalls For Patients With VP Shunt Complications

  1. “I am concerned that my patient may have a VP shunt obstruction. The neurosurgical resident is at the bedside and pumps the shunt, which has free flow. Because of this, he wants to send the patient home.”
    Pumping the shunt has been shown not to be a reliable predictor of shunt patency. If clinical suspicion for an obstruction is still high, further workup and management may be needed.
  2. “My patient has clinical signs of shunt obstruction, but has a normal head CT scan and shunt series, so his symptoms must not be related to his shunt.”
    Unfortunately, many patients can have normal or unchanged imaging and still have a shunt complication. If the suspicion for a shunt complication is high, it is advisable to discuss the case with the patient’s neurosurgeon and consider further imaging or intervention.
  3. “My patient has large ventricles on a head CT scan, so there must be a shunt malfunction.”
    Comparing the studies with previous imaging should always be done, whenever possible, to determine whether there is any change in the ventricle size. Also, the clinical picture should be taken into consideration.
  4. “My patient is presenting with signs of a possible shunt complication. The head CT scan is normal, and, therefore, a shunt series is not necessary.”
    Although rare, there are cases of a normal head CT scan with an abnormal shunt series. Therefore, a shunt series should be obtained.
  5. “Every patient with a VP shunt and fever needs laboratory work and diagnostic studies.”
    The clinical picture needs to be considered for each patient. A focused history and physical examination should be obtained and key features of shunt infection should be focused upon, such as bulging fontanel, drowsiness, lethargy, or erythema around the shunt. Laboratory values are not specific. Not all shunt infections need imaging—if a shunt infection is suspected, a shunt tap is needed.
  6. “My patient with a VP shunt appears ill, but there is no history of fever. Therefore, a shunt infection can be excluded.”
    A patient can have a shunt infection without fever. Other signs and symptoms may be present that can suggest a possible shunt infection. A full history and physical examination should be obtained.
  7. “My patient with a VP shunt presents with abdominal pain and vomiting; this cannot be related to the shunt.”
    Abdominal pain and vomiting in a patient with a VP shunt can be a sign of shunt malfunction, or due to common viral or other illnesses. For example, patients with constipation and a pseudocyst can present similarly. Again, a detailed history and physical examination are needed, as well as potential imaging.
  8. “Although my patient is stable, I am concerned about a possible shunt infection, so I will perform a shunt tap.”
    This is an option, if this has been discussed with the neurosurgeon and you feel comfortable performing a tap. Typically, however, a shunt tap is performed by an emergency physician only emergently when a patient is acutely decompensating. There are many risks associated with shunt taps, and this procedure should be performed by a neurosurgeon, if possible.
  9. “My patient with a VP shunt has clinical signs of increased ICP with impending herniation, but I want to wait for neurosurgery to perform a shunt tap.”
    As stated in pitfall 8, this is the only circumstance when an emergency physician is truly obligated to perform a shunt tap, as it is a potentially life-saving intervention.
  10. “My patient with a history of seizures and a VP shunt presented with a breakthrough seizure; this must be a shunt malfunction or infection.”
    Seizures alone are not necessarily a clinical manifestation of a shunt infection or malfunction. The more concerning signs and symptoms the patient has, the higher the likelihood of a VP shunt malfunction or infection.

Tables and Figures

Table 1. Shunt Complications

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study are included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Thompson DN. Hydrocephalus. Surgery. 2007;25(12):522-525. (Review article)
  2. Baru JS, Bloom DA, Muraszko K, et al. John Holter’s shunt. J Am Coll Surg. 2001;192(1):79-85. (Review article)
  3. Pople IK. Hydrocephaus and shunts: what the neurologist should know. J Neurol Neurosurg Psychiatry. 2002;73:i17-i22. (Review article)
  4. Wu Y, Green NL, Wrensch MR, et al. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery. 2007;61(3):557-562. (Retrospective study; 14,455 patients)
  5. Lee P, DiPatri AJ Jr. Evaluation of suspected cerebrospinal fluid shunt complications in children. Clin Pediatr Emerg Med. 2008;9(2):76-82. (Review article)
  6. Bragg CL, Edwards-Beckett J, Eckle N, et al. Ventriculoperitoneal shunt dysfunction and constipation: a chart review. J Neurosci Nurs. 1994;26(5):265-269. (Retrospective study; 51 patients)
  7. Browd SR, Gottfried ON, Ragel BT, et al. Failure of cerebrospinal fluid shunts: part II: overdrainage, loculation, and abdominal complications. Pediatr Neurol. 2006;34(3):171-176. (Review article)
  8. Drake JM, Kestle JR, Milner R, et al. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurg. 1998;43(2):294-303. (Randomized controlled trial; 344 patients)
  9. Davis SE, Levy LM, McComb JG, et al. Does age or other factors influence the incidence of ventriculoperitoneal shunt infections? Pediatr Neurosurg. 1999;30:253-257. (Retrospective study; 1193 patients)
  10. McGirt MJ, Leveque JC, Wellons JC 3rd, et al. Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience. Pediatr Neurosurg. 2002;36:248-255. (Retrospective study; 353 patients)
  11. Tuli S, Drake J, Lawless J, et al. Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg. 2000;92:31-38. (Prospective study; 839 patients)
  12. Reddy GK, Bollam P, Caldito G, et al. Ventriculoperitoneal shunt complications in hydrocephalus patients with intracranial tumors: an analysis of relevant risk factors. J Neurooncol. 2011;103(2):333-342. (Retrospective study; 187 patients)
  13. Appelgren T, Zetterstrand S, Elfversson J, et al. Long-term outcome after treatment of hydrocephalus in children. Pediatr Neurosurg. 2010;46(3):221-226. (Retrospective study; 98 patients)
  14. Madikians A, Conway EE Jr. Cerebrospinal fluid shunt problems in pediatric patients. Pediatr Ann. 1997;26(1O):613-620. (Review article)
  15. * Kim TY, Stewart G, Voth M, et al. Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department. Pediatr Emerg Care. 2006;22(1):28-34. (Retrospective study; 352 patients)
  16. Green AL, Pereira EA, Kelly D, et al. The changing face of paediatric hydrocephalus: a decade’s experience. J Clin Neurosci. 2007;14(11):1049-1054. (Retrospective study; 253 patients)
  17. Goeser CD, McLeary MS, Young LW. Diagnostic imaging of ventriculoperitoneal shunt malfunctions and complications. Radiographics. 1998;18(3):635-651. (Review article)
  18. Mwachaka PM, Obonyo NG, Mutiso BK, et al. Ventriculoperitoneal shunt complications: a three-year retrospective study in a Kenyan national teaching and referral hospital. Pediatr Neurosurg. 2010;46(1):1-5. (Retrospective study; 117 patients)
  19. Mohammed W, Wiig U, Caird J. Spontaneous knot; a rare cause of ventriculoperitoneal shunt blockage. Br J Neurosurg. 2011;25(1):113-114. (Case report)
  20. Borcek AO, Civi S, Golen M, et al. An unusual ventriculo-peritoneal shunt complication: spontaneous knot formation. Turk Neurosurg. 2012;22(2):261-264. (Case report)
  21. Sainte-Rose C, Piatt JH, Renier D, et al. Mechanical complications in shunts. Pediatr Neurosurg. 1991;17(1):2-9. (Retrospective study; 1719 patients)
  22. Browd SR, Ragel BT, Gottfried ON, et al. Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol. 2006;34(2):83-92. (Review article)
  23. Cozzens JW, Chandler JP. Increased risk of distal ventriculoperitoneal shunt obstruction associated with slit valves or distal slits in the peritoneal catheter. J Neurosurg. 1997;87(5):682-686. (Retrospective study; 71 patients)
  24. Martinez-Lage JF, Martos-Tello JM, Ros-de-San Pedro J, et al. Severe constipation: an under-appreciated cause of VP shunt malfunction: a case-based update. Childs Nerv Syst. 2008;24(4):431-435. (Case report)
  25. Muzumdar D, Ventureyra EC. Transient ventriculoperitoneal shunt malfunction after chronic constipation: case report and review of literature. Childs Nerv Syst. 2007;23(4):455-458. (Case report)
  26. Kural C, Kirik A, Pusat S, et al. Late calcification and rup-ture: a rare complication of ventriculoperitoneal shunting. Turk Neurosurg. 2012;22(6):779-782. (Case report)
  27. Yamazaki T, Shimizu S, Sagiuchi T, et al. Intractable seizures associated with proximal migration of a ventriculoperitoneal shunt. Case report. Neurol Med Chir (Tokyo). 2005;45(11):600- 603. (Case report)
  28. Coley BD, Kosnik EJ. Abdominal complications of ventriculoperitoneal shunts in children. Semin Ultrasound CT MR. 2006;27(2):152-160. (Review article)
  29. Born M, Reichling S, Schirrmeister J. Pleural effusion: beta-trace protein in diagnosing ventriculoperitoneal shunt complications. J Child Neurol. 2008;23(7):810-812. (Case report)
  30. Di Roio C, Mottolese C, Cayrel V, et al. Respiratory distress caused by migration of ventriculoperitoneal shunt catheter into the chest cavity. Intensive Care Med. 2000;26(6):818. (Case report)
  31. Nourisamie K, Vyas P, Swanson KF. Two unusual compli-cations of ventriculoperitoneal shunts in the same infant. Pediatr Radiol. 2001;31(11):814-816. (Case report)
  32. Frazier JL, Wang PP, Patel SH, et al. Unusual migration of the distal catheter of a ventriculoperitoneal shunt into the heart: case report. Neurosurgery. 2002;51(3):819-822. (Case report)
  33. Ozveren MF, Kazez A, Cetin H, et al. Migration of the abdominal catheter of a ventriculoperitoneal shunt into the scrotum--case report. Neurol Med Chir (Tokyo). 1999;39(4):313- 315. (Case report)
  34. Fisher RA, Rodziewicz G, Selman WR, et al. Liver abscess: complication of a ventriculoperitoneal shunt. Neurosurgery. 1984;14(4):480-482. (Case report)
  35. Duhaime AC. Evaluation and management of shunt infections in children with hydrocephalus. Clin Pediatr (Phila). 2006;45(8):705-713. (Review article)
  36. Turgut M, Alabaz D, Erbey F, et al. Cerebrospinal fluid shunt infections in children. Pediatr Neurosurg. 2005;41(3):131-136. (Retrospective study; 35 patients)
  37. von der Brelie C, Simon A, Groner A, et al. Evaluation of an institutional guideline for the treatment of cerebrospinal fluid shunt-associated infections. Acta Neurochir (Wien). 2012;154(9):1691-1697. (Retrospective study; 78 patients)
  38. Gassas A, Kennedy J, Green G, et al. Risk of ventriculoperitoneal shunt infections due to gastrostomy feeding tube insertion in pediatric patients with brain tumors. Pediatr Neurosurg. 2006;42(2):95-99. (Retrospective study; 51 patients)
  39. Pinto K, Jerkins GR, Noe HN. Ventriculoperitoneal shunt infection after bladder augmentation. Urology. 1999;54(2):356- 358. (Retrospective study; 21 patients)
  40. Sardelic S, Karanovic J, Rubic Z, et al. Late ventriculoperitoneal shunt infection caused by Shewanella algae. Pediatr Infect Dis J. 2010;29(5):475-477. (Case report)
  41. Viraraghavan R, Jantausch B, Campos J. Late-onset central nervous system shunt infections with Propionibacterium acnes: diagnosis and management. Clin Pediatr (Phila). 2004;43(4):393-397. (Case report)
  42. Baradkar VP, Mathur M, Sonavane A, et al. Candidal infections of ventriculoperitoneal shunts. J Pediatr Neurosci. 2009;4(2):73-75. (Retrospective study; 6 patients)
  43. Veeravagu A, Ludwig C, Camara-Quintana JQ, et al. Fungal infection of a ventriculoperitoneal shunt: histoplasmosis diagnosis and treatment. World Neurosurg. 2013;80(1-2):222. e225-e213. (Case report)
  44. Agarwal P, Malapure SM, Gupta R, et al. Round worm migration along ventriculoperitoneal shunt tract: a rare complication. J Postgrad Med. 2000;46(1):37-38. (Case report)
  45. Akbari SH, Holekamp TF, Murphy TM, et al. Surgical management of complex multiloculated hydrocephalus in infants and children. Childs Nerv Syst. 2015;31(2):243-249. (Retrospective study; 25 patients)
  46. Ersahin Y, Yurtseven T. Rare complications of shunt infection. Pediatr Neurosurg. 2004;40(2):90-92. (Review article)
  47. Kanev PM, Sheehan JM. Reflections on shunt infection. Pediatr Neurosurg. 2003;39(6):285-290. (Retrospective study; 562 procedures)
  48. da Silva PS, Suriano IC, Neto HM. Slitlike ventricle syndrome: a life-threatening presentation. Pediatr Emerg Care. 2009;25(10):674-676. (Case report)
  49. Buyukyavuz BI, Duman L, Karaaslan T, et al. Hyponatremic seizure due to huge abdominal cerebrospinal fluid pseudocsyt in a child with ventriculoperitoneal shunt: a case report. Turk Neurosurg. 2012;22(5):656-658. (Case report)
  50. Oemus K, Gerlach H, Rath FW. [A rare complication of shunt therapy. Metastasis of brain tumors by cerebrospinal fluid drainage]. Zentralbl Neurochir. 1992;53(1):25-32. (Case report)
  51. Rickert CH. Abdominal metastases of pediatric brain tumors via ventriculo-peritoneal shunts. Childs Nerv Syst. 1998;14(1- 2):10-14. (Literature review; 35 patients)
  52. * Piatt JH Jr, Garton HJ. Clinical diagnosis of ventriculoperitoneal shunt failure among children with hydrocephalus. Pediatr Emerg Care. 2008;24(4):201-210. (Retrospective study; 248 shunts)
  53. Isaacman DJ, Poirier MP, Hegenbarth M, et al. Ventriculoperitoneal shunt management. Pediatr Emerg Care. 2003;19(2):119-125. (Review article)
  54. Tsze DS, Steele DW. Neurosurgical emergencies, non-traumatic. In: Fleisher GR, Ludwid S, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins; 2010:1588-1590. (Textbook)
  55. Lee TT, Uribe J, Ragheb J, et al. Unique clinical presentation of pediatric shunt malfunction. Pediatr Neurosurg. 1999;30(3):122-126. (Retrospective study; 65 patients)
  56. * Garton HJ, Kestle JR, Drake JM. Predicting shunt failure on the basis of clinical symptoms and signs in children. J Neurosurg. 2001;94:202-210. (Retrospective study; 431 encounters)
  57. Watkins L, Hayward R, Andar U, et al. The diagnosis of blocked cerebrospinal fluid shunts: a prospective study of referral to a paediatric neurosurgical unit. Childs Nerv Syst. 1994;10(2):87-90. (Prospective study; 45 patients)
  58. Barnes NP, Jones SJ, Hayward RD, et al. Ventriculoperitoneal shunt block: what are the best predictive clinical indicators? Arch Dis Child. 2002;87(3):198-201. (Prospective study; 53 patients)
  59. * Johnson DL, Conry J, O’Donnell R. Epileptic seizure as a sign of cerebrospinal fluid shunt malfunction. Pediatr Neurosurg. 1996;24(5):223-227. (Retrospective study; 817 patients)
  60. Hack CH, Enrile BG, Donat JF, et al. Seizures in relation to shunt dysfunction in children with myelomeningocele. J Pediatr. 1990;116:57-60. (Retrospective study; 346 patients)
  61. Sivaganesan A, Krishnamurthy R, Sahni D, et al. Neuroimaging of ventriculoperitoneal shunt complications in children. Pediatr Radiol. 2012;42(9):1029-1046. (Review article)
  62. * Piatt JH Jr. Physical examination of patients with cerebrospinal fluid shunts: is there useful information in pumping the shunt. Pediatrics 1992;89:470-473. (Prospective study; 200 patients)
  63. Bromby A, Czosnyka Z, Allin D, et al. Laboratory study on “intracranial hypotension” created by pumping the chamber of a hydrocephalus shunt. Cerebrospinal Fluid Res. 2007;4:2. (Laboratory study; 11 shunt models)
  64. Huang CY, Hung YC, Tai SH, et al. Cerebellar hemorrhage after multiple manual pumping tests of a ventriculoperitoneal shunt: a case report. Kaohsiung J Med Sci. 2009;25(1):29-33. (Case report)
  65. Li V, Dias MS. The results of a practice survey on the management of patients with shunted hydrocephalus. Pediatr Neurosurg. 1999;30(6):288-295. (Survey; 261 respondents)
  66. DeFlorio RM, Shah CC. Techniques that decrease or eliminate ionizing radiation for evaluation of ventricular shunts in children with hydrocephalus. Semin Ultrasound CT MR. 2014;35(4):365-373. (Review article)
  67. Zorc JJ, Krugman SD, Ogborn J, et al. Radiographic evaluation for suspected cerebrospinal fluid shunt obstruction. Pediatr Emerg Care. 2002;18(5):337-340. (Retrospective study; 233 patients)
  68. Winston KR, Lopez JA, Freeman J. CSF shunt failure with stable normal ventricular size. Pediatr Neurosurg. 2006;42(3):151-155. (Retrospective study; 12 patients)
  69. O’Brien DF, Taylor M, Park TS, et al. A critical analysis of “normal” radionucelotide shuntograms in patients subsequently requiring surgery. Childs Nerv Syst. 2003;19:337-341. (Retrospective study; 149 studies)
  70. Iskandar BJ, McLaughlin C, Mapstone TB, et al. Pitfalls in the diagnosis of ventricular shunt dysfunction: radiology reports and ventricular size. Pediatrics. 1998;101(6):1031-1036. (Retrospective study; 100 patients)
  71. Goske MJ, Applegate KE, Boylan J, et al. The Image Gently campaign: working together to change practice. AJR Am J Roentgenol. 2008;190(2):273-274. (Practice guidelines)
  72. Udayasankar UK, Braithwaite K, Arvaniti M, et al. Low-dose nonenhanced head CT protocol for follow-up evaluation of children with ventriculoperitoneal shunt: reduction of radiation and effect on image quality. AJNR Am J Neuroradiol. 2008;29(4):802-806. (Retrospective study; 92 patients)
  73. George KJ, Roy D. A low radiation computed tomography protocol for monitoring shunted hydrocephalus. Surg Neurol Int. 2012;3:103. (Pilot study; 10 patients)
  74. Pindrik J, Huisman TA, Mahesh M, et al. Analysis of limited-sequence head computed tomography for children with shunted hydrocephalus: potential to reduce diagnostic radiation exposure. J Neurosurg Pediatr. 2013;12(5):491-500. (Retrospective study; 50 patients)
  75. Alhilali LM, Dohatcu AC, Fakhran S. Evaluation of a limited three-slice head CT protocol for monitoring patients with ventriculoperitoneal shunts. AJR Am J Roentgenol. 2013;201(2):400-405. (Retrospective study; 231 studies)
  76. Desai KR, Babb JS, Amodio JB. The utility of the plain radiograph “shunt series” in the evaluation of suspected ventriculoperitoneal shunt failure in pediatric patients. Pediatr Radiol. 2007;37(5):452-456. (Retrospective study; 238 patients)
  77. * Pitetti R. Emergency department evaluation of ventricular shunt malfunction: is the shunt series really necessary? Pediatr Emerg Care. 2007;23(3):137-141. (Retrospective study; 291 patients)
  78. May CH, Aurisch R, Kornrumpf D, et al. Evaluation of shunt function in hydrocephalic patients with the radionuclide 99mTc-pertechnetate. Childs Nerv Syst. 1999;15(5):239-244. (Prospective study; 85 children)
  79. Ouellette D, Lynch T, Bruder E, et al. Additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department. Pediatr Emerg Care. 2009;25(12):827-830. (Retrospective study; 69 patients)
  80. Hamburg LM, Kessler DO. Rapid evaluation of ventriculo-peritoneal shunt function in a pediatric patient using emergency ultrasound. Pediatr Emerg Care. 2012;28(7):726-727. (Case report)
  81. Zaidi SJ, Yamamoto LG. Optic nerve sheath diameter measurements by CT scan in ventriculoperitoneal shunt obstruction. Hawaii J Med Public Health. 2014;73(8):251-255. (Retrospective study; 14 patients)
  82. Malayeri AA, Bavarian S, Mehdizadeh M. Sonographic evaluation of optic nerve diameter in children with raised intracranial pressure. J Ultrasound Med. 2005;24(2):143-147. (Randomized controlled trial; 156 patients)
  83. Le A, Hoehn ME, Smith ME, et al. Bedside sonographic measurement of optic nerve sheath diameter as a predictor of increased intracranial pressure in children. Ann Emerg Med. 2009;53(6):785-791. (Prospective study; 64 patients)
  84. * Iskandar BJ, Sansone JM, Medow J, et al. The use of quick-brain magnetic resonance imaging in the evaluation of shunt-treated hydrocephalus. J Neurosurg. 2004;101(2 Suppl):147-151. (Retrospective study)
  85. Boyle TP, Paldino MJ, Kimia AA, et al. Comparison of rapid cranial MRI to CT for ventricular shunt malfunction. Pediatrics. 2014;134(1):e47-e54. (Retrospective study; 298 patients)
  86. Missios S, Quebada PB, Forero JA, et al. Quick-brain magnetic resonance imaging for nonhydrocephalus indications. J Neurosurg Pediatr. 2008;2(6):438-444. (Retrospective study; 1146 images)
  87. O’Neill BR, Pruthi S, Bains H, et al. Rapid sequence magnetic resonance imaging in the assessment of children with hydro-cephalus. World Neurosurg. 2013;80(6):e307-e312. (Retrospective study; 50 patients)
  88. Wait SD, Lingo R, Boop FA, et al. Eight-second MRI scan for evaluation of shunted hydrocephalus. Childs Nerv Syst. 2012;28(8):1237-1241. (Retrospective study; 44 patients)
  89. Miller JH, Walkiewicz T, Towbin RB, et al. Improved delineation of ventricular shunt catheters using fast steady-state gradient recalled-echo sequences in a rapid brain MR imaging protocol in nonsedated pediatric patients. AJNR Am J Neuroradiol. 2010;31(3):430-435. (Retrospective study; 179 patients)
  90. Ashley WW Jr, McKinstry RC, Leonard JR, et al. Use of rapid-sequence magnetic resonance imaging for evaluation of hydrocephalus in children. J Neurosurg. 2005;103(2 Suppl):124-130. (Retrospective study; 67 scans)
  91. Kontny U, Hofling B, Gutjahr P, et al. CSF shunt infections in children. Infection. 1993;21(2):89-92. (Retrospective study; 350 procedures)
  92. Lan CC, Wong TT, Chen SJ, et al. Early diagnosis of ventriculoperitoneal shunt infections and malfunctions in children with hydrocephalus. J Microbiol Immunol Infect. 2003;36(1):47- 50. (Retrospective study; 129 patients)
  93. McClinton D, Carraccio C, Englander R. Predictors of ventriculoperitoneal shunt pathology. Pediatr Infect Dis J. 2001;20(6):593-597. (Retrospective study; 81 patients)
  94. Fulkerson DH, Boaz JC. Cerebrospinal fluid eosinophilia in children with ventricular shunts. J Neurosurg Pediatr. 2008;1(4):288-295. (Retrospective study; 93 patients)
  95. Bezerra S, Frigeri TM, Severo CM, et al. Cerebrospinal fluid eosinophilia associated with intraventricular shunts. Clin Neurol Neurosurg. 2011;113(5):345-349. (Case report)
  96. Fulkerson DH, Sivaganesan A, Hill JD, et al. Progression of cerebrospinal fluid cell count and differential over a treatment course of shunt infection. J Neurosurg Pediatr. 2011;8(6):613-619. (Retrospective study; 105 patients)
  97. Schuhmann MU, Ostrowski KR, Draper EJ, et al. The value of C-reactive protein in the management of shunt infections. J Neurosurg. 2005;103(3 Suppl):223-230. (Retrospective study; 59 patients)
  98. Asi-Bautista MC, Heidemann SM, Meert KL, et al. Tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 concentrations in cerebrospinal fluid predict ventriculoperitoneal shunt infection. Crit Care Med. 1997;25(10):1713-1716. (Prospective observational study; 64 patients)
  99. Scribano PV, Pool S, Smally AJ. Comparison of ventriculoperitoneal shunt tap and lumbar puncture in a child with meningitis. Pediatr Emerg Care. 2002;18(4):E1-E3. (Case report)
  100. Leib SL, Boscacci R, Gratzl O, et al. Predictive value of cerebrospinal fluid (CSF) lactate level versus CSF/blood glucose ratio for the diagnosis of bacterial meningitis following neurosurgery. Clin Infect Dis. 1999;29(1):69-74. (Retrospective study; 73 patients)
  101. Conen A, Walti LN, Merlo A, et al. Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis. 2008;47(1):73-82. (Retrospective study; 78 episodes)
  102. Roberts JR. Robert’s and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2014. (Textbook)
  103. Ladde JG. Central nervous system procedures and devices. In: Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. China: The McGraw-Hill Companies, Inc; 2011. (Textbook)
  104. Maartens NF, Aurora P, Richards PG. An unusual complication of tapping a ventriculoperitoneal shunt. Eur J Paediatr Neurol. 2000;4(3):125-129. (Case report)
  105. Vega RA, Buscher MG, Gonzalez MS, et al. Sonographic localization of a nonpalpable shunt: Ultrasound-assisted ventricular shunt tap. Surg Neurol Int. 2013;4:101. (Case report)
  106. Zeiler FA, Teitelbaum J, West M, et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care. 2014;21(1):163- 173. (Systematic review)
  107. Horton C, Byrd L, Lucht H, et al. Emergency care of children with high-technology neurologic disorders. Clin Pediatr Emerg Med. 2012;13(2):114-120. (Case vignettes)
  108. Vernet O, Campiche R, de Tribolet N. Long-term results after ventriculoatrial shunting in children. Childs Nerv Syst. 1993;9(5):253-255. (Prospective study; 120 patients)
  109. Keucher TR, Mealey J Jr. Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg. 1979;50(2):179-186. (Prospective study; 228 patients)
  110. Ziegler MM, Azizkhan RG, von Allmen D, et al. Operative Pediatric Surgery. China: McGraw-Hill Education; 2014. (Textbook)
  111. Sciubba DM, Stuart RM, McGirt MJ, et al. Effect of antibiotic-impregnated shunt catheters in decreasing the incidence of shunt infection in the treatment of hydrocephalus. J Neurosurg. 2005;103(2 Suppl):131-136. (Retrospective study; 211 patients)
  112. Aryan HE, Meltzer HS, Park MS, et al. Initial experience with antibiotic-impregnated silicone catheters for shunting of cerebrospinal fluid in children. Childs Nerv Syst. 2005;21(1):56-61. (Prospective study; 31 patients)
  113. Govender ST, Nathoo N, van Dellen JR. Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus. J Neurosurg. 2003;99(5):831-839. (Prospective randomized controlled trial; 110 patients)
  114. Kan P, Kestle J. Lack of efficacy of antibiotic-impregnated shunt systems in preventing shunt infections in children. Childs Nerv Syst. 2007;23(7):773-777. (Retrospective study; 160 procedures)
  115. Ritz R, Roser F, Morgalla M, et al. Do antibiotic-impregnated shunts in hydrocephalus therapy reduce the risk of infection? An observational study in 258 patients. BMC Infect Dis. 2007;7:38. (Retrospective study; 258 patients)
  116. Steinbok P, Milner R, Agrawal D, et al. A multicenter multinational registry for assessing ventriculoperitoneal shunt infections for hydrocephalus. Neurosurgery. 2010;67(5):1303-46. (Prospective multicenter noncontrolled open-label registry; 440 patients)
  117. Demetriades AK, Bassi S. Antibiotic resistant infections with antibiotic-impregnated Bactiseal catheters for ventriculoperitoneal shunts. Br J Neurosurg. 2011;25(6):671-673. (Prospective study; 125 patients)
  118. Abramo TJ, Zhou C, Estrada C, et al. Innovative application of cerebral rSO2 monitoring during shunt tap in pediatric ventricular malfunctioning shunts. Pediatr Emerg Care. 2014. (Prospective case series; 94 patients)
  119. Rocque BG, Lapsiwala S, Iskandar BJ. Ventricular shunt tap as a predictor of proximal shunt malfunction in children: a prospective study. J Neurosurg Pediatr. 2008;1(6):439-443. (Prospective study; 51 patients)
  120. Miller JP, Fulop SC, Dashti SR, et al. Rethinking the indications for the ventriculoperitoneal shunt tap. J Neurosurg Pediatr. 2008;1(6):435-438. (Retrospective study; 155 patients)
  121. Petrella G, Czosnyka M, Keong N, et al. How does CSF dynamics change after shunting? Acta Neurol Scand. 2008;118(3):182-188. (Retrospective study; 25 patients)
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